Expert advice was obtained from two independent general
practitioners.

Complaint

On 15 May 2000 the Commissioner received a complaint from Dr A
on behalf of his daughter, Ms B, and son-in-law about the care
provided to his grandson, Mr C, by a rural medical clinic, Dr D and
Dr E. The complaint initially included allegations about
nursing staff who had contact with Mr C. However, this part
of the investigation was discontinued following consultation with
Ms B in July 2000.

Dr D

During the afternoon of 9 April 2000 Dr D did not diagnose
meningococcal disease in Mr C.

On the same occasion Dr D did not, in a timely manner,
treat Mr C for meningococcal disease or refer him to hospital for
further care.

Dr D did not properly monitor Mr C's vital signs, namely
his temperature, pulse, respiration and blood pressure, ignored a
probable petechial haemorrhage, and did not observe his eyes even
when requested to do so by his mother, Ms B

Dr D did not heed the concerns of Ms B that her son may
have meningitis.

Dr E

During the afternoon of 9 April 2000 Dr E, when asked for a
second opinion by Dr D regarding Mr C, did not recognise or
diagnose his meningococcal disease.

Information reviewed

Statements, correspondence and interview notes from:

Dr
A
Grandfather

Ms
B
Mother

Dr
D
Provider

Dr
E
Provider

Dr
F
Medical Director of the medical clinic

Professor G Medical Professor invited to
comment by Dr A

Documents:

Clinical notes from the medical clinic

Ambulance Case Record

Newspaper article from local newspaper

Comparative list of signs and symptoms between meningitis and
meningococcal septicaemia supplied to Ms B by a hospital
specialist

D. Aponso and C. Bullen, "Presenting features of meningococcal
disease, public health messages and media publicity: are they
consistent?" New ZealandMedical Journal,
2001.

Reports supplied by Dr A from Dr I and Dr J

Reports supplied by Dr F from Dr K, Dr L and Dr M

Response to provisional opinion from Dr A, including a report
from Professor G.

Reports to the Commissioner from two independent general
practitioner advisors.

Information gathered during investigation

Mr C was four years old when he died at a children's public
hospital on 21 April 2000 from complications of meningococcal
disease.

Pre-assessment history

Ms B recalled that on the return trip home from the supermarket
on the morning of 9 April 2000 Mr C felt hot, but when the window
was opened he felt cold. Mr C also complained that the sun
hurt his eyes. On arriving home, Mr C helped take in the
groceries but then felt tired and lay down on his mother's
bed. When Ms B, who was a nurse, checked Mr C about 11am she
found Mr C's "hands cold, torso warm but not hot. Again I
thought this strange, as the day was a beautiful warm clear end of
summer day. I immediately thought that the only thing that
could cause this was peripheral shutdown. I checked his feet
and they too were coldish. He became hot and shook
intermittently." Ms B said Mr C was "normally full of
youthful energy" but had also "complained of a sore side". Ms
B advised that after waiting for an expected guest coming to Mr C's
planned birthday picnic and attempting to contact Mr C's father,
she took Mr C straight to a nearby clinic. The drive from
their residence to the clinic takes approximately 30 minutes.

Ms B arrived at the clinic soon after 1.00pm.

Assessment at the clinic

Staff nurse, Ms G was informed by the receptionist at
approximately 1.20pm that Mr C was vomiting in the triage
room. Ms G recorded Mr C's condition, as reported to her by
Ms B, in the triage section of the clinical notes as: "Feverish
since this afternoon, photophobia, rash, worsened since 1100
vomiting [no] diarrhoea. c/o headache also sore R) arm and R)
leg." Mr C's temperature was 39.8 and his weight 14
kilograms. Ms B stated that Mr C needed supporting as he was
weighed but the nurse had said to her "not to worry about holding
him". No known allergies were noted. Pulse, respiratory
rate and blood pressure were not recorded; observations of pulse
and blood pressure were not routinely taken at the clinic for every
febrile child.

Dr D saw Mr C almost immediately after he was triaged and noted
in the clinical notes: "Well prior, acute onset, vomited x1, [no]
diarrhoea, [no] rash. Quiet." Dr D found that
"cardiovascular, respiratory, ear, nose and throat and abdominal
systems were all normal" and there was "[no] petechial rash, CNS
[no] photophobia, [no] meningism, Kernig -ve [negative]". Ms
B disputes that Mr C did not have photophobia as she recalled Mr C
complaining to her that the sun hurt his eyes. When Dr D
asked Mr C if the light hurt his eyes, Ms B stated that Mr C had
replied, "That [artificial] light does not hurt my eyes but the sun
does."

Dr D diagnosed a "probable viral illness". Dr D stated
that he reached his diagnosis on the basis of the following
information:

"A suddenly sick child - normally very healthy who became sick
about 2 hours earlier. He was febrile (39.8). He had
vomited in reception. He was probably 'floppy' and weak when
the nurse tried to weigh him. He responded to the paracetamol
with a reduction in temp and improved wellbeing. …"

Dr D prescribed Pamol syrup and Brufen syrup, which were given
at 1.30pm and 1.50pm respectively. Dr D also requested that
Mr C's temperature be monitored every 15 minutes. The record
indicates a decrease in temperature from 39.7 to 38.7 at 2.30pm and
then to 36.5 at an unrecorded time, later advised by Ms G to be
approximately 3.15pm. Ms B confirmed that Mr C's temperature
was monitored every 15 minutes although not all temperature
measurements were recorded. Ms B later stated her views:

"[Mr C was] hypothermic not normothermic as suggested by [Dr
D]. In all my years as a mother and a nurse temperatures do
not come down from 39.8 to 36.5 so quickly. I believe [Mr C]
was progressing further into his shocked state and again the
professionals did not think of this. …"

Dr D checked in on Mr C several times over the next couple of
hours while he slept. Dr D confirms that during this time he
discussed meningitis with Ms B and the signs and symptoms to look
for. Ms B expressed her concern that Mr C might have
meningitis. Ms B later stated that she also expressed concern
to Dr D that Mr C had meningococcal disease. Ms B advised she
told Dr D that her father was "a GP who had diagnosed many cases
[and] had remarked that many cases had this 'odd look about the
eyes'. That they looked through you rather than at
you." Dr I, a colleague of Dr A, confirmed this
observation. "The far away look in his eyes is a most
important sign. … This is a feature noted by myself as well
as my colleagues as a common and significant sign in adult as well
as paediatric patients with meningococcal septicaemia." Ms B
said that Mr C's eyes "were doing just this and I relayed this to
the doctor".

Ms B also advised that she asked Dr D whether he had taken Mr
C's pulse, which she had taken as measuring 162. Ms B stated
that Dr D replied to her "he hadn't but had felt it, and it was
rising". Dr D has said it would be most unlikely he would
have stated any trend in Mr C's pulse because it was not taken
serially. Dr D also said it was difficult to count a pulse of
140, let alone 162.

Towards the end of the time that he and his mother were at the
clinic, Mr C was resting and Ms B stated:

"I noticed a small deep purple spot (this resembled a flat skin
stone bruise) with a red halo on [Mr C's] right arm in the ante
cubital fossa. This spot was not large, about 2mm in
diameter. I showed this to [Dr D] who then got out a medical
textbook. He showed me photos of what the 'rash'
(meningococcal) looked like. He continued to say it was a
viral infection."

Dr D recalled Mr C's condition at about 3.20pm, when he woke
up:

"[Mr C] looked very well, was afebrile and again there were no
signs of meningitis or a petechial rash. His mother and I
checked him all over for spots and did find 2 blemishes on his
right upper arm. These did not look petechial at all, but
because she was unsure whether they were new or not, I asked my
colleague, [Dr E], to review [Mr C]."

In the clinical notes Dr D recorded that Mr C was "Well.
[Decreased] temp, no meningism. No evidence of meningitis.
Review prn [as necessary]."

Ms B stated that she showed both Dr D and Dr E the "little spot"
in Mr C's right arm but that they concentrated on a freckle on Mr
C's chest.

Dr E examined Mr C at Dr D's request. Dr E later
wrote:

"… [Dr D] asked me to look at a spot on his chest, explaining to
me, he was a 4 year old boy who'd presented with a high temperature
[subsequently settled] and vomiting.

The spot on [Mr C's] chest was circular, well defined, raised
approximately 1-2mm, light brown in colour and resembled a raised
freckle or skin tag. At the same time, I noted [Mr C] was
alert, co-operative, quiet but spoke to me. He could easily
place his chin on his chest with no signs of neck stiffness or
photophobia. Kernig negative.

I agreed with [Dr D] that the spot was not representative of the
rash typically described with meningococcal disease.

I remember overhearing [Dr D] ask [Mr C's] mother to stay in
town for the afternoon, as she lived so far away."

Ms B confirmed that Dr D asked her if she could stay in town for
a couple of hours, in case there was any change in Mr C's
condition, since they lived 30 minutes away. Ms B stated: "I
was left alone and as Mr C woke and was conversant and the most
awake he'd been for hours, I decided to go home due to my other
children. …"

Ms G stated in regard to Ms B's leaving the clinic:

"At approximately 1520 [3.20pm] [Mr C] appeared more alert and
had stopped vomiting for the past hour and a half, and his
temperature had reduced to 36.5. … [Ms B] stated to [Dr D]
she was happy to take [Mr C] home, as his general condition had
improved and his temperature had reduced. I heard [Dr D]
advise [Ms B] that if [Mr C's] condition changed, to bring him
straight back to clinic or to go to the hospital."

Dr D stated he also offered Ms B the option of admitting Mr C to
hospital for observation. Ms B denied that this offer was
ever made.

Soon after 3.20pm Ms B left the clinic with Mr C to get his
prescription filled at the pharmacy next door. However, Mr C
vomited again outside the pharmacy and was immediately returned to
the clinic. Staff nurse, Ms H, who had commenced her duty at
3pm, passed this information to Dr D, "who immediately went to see
the patient. I recall the patient being very pale." Ms
B reported that "[Dr D] stated that he too was getting paranoid -
meaning that this may be a meningococcal infection".

Ms G stated as follows:

"[I] went out to the reception and brought [Mr C] and [Ms B]
into a triage room. [Dr D] came into the room straight
away. I heard [Dr D] advise [Ms B] to stay for a bit longer
in the clinic, seeing as they lived out of the city. [Dr D]
advised me to keep [Mr C] and to observe his condition till further
notice. Approximately 15-30 mins later [Ms B] stated that she
was happy to take [Mr C] home as he had improved. I informed
[Dr D] of this and [Mr C] and [Ms B] left the clinic at
approximately 1600 hours [4pm]."

Once home, [Mr C] played briefly with his friend but then
continued to vomit. [Ms B] sponged [Mr C]. The spot on
his arm had not multiplied. [Mr C] was "not able to keep
anything down". Staff nurse Ms H recalled receiving a phone
call from [Ms B] at approximately 8.30pm. [Ms B] reported
that [Mr C] was "floppy" and she was bringing him in. Staff
nurse Ms H further stated that at "approximately, 2140 hrs [9.40pm,
corrected from 2115hrs, 9.15pm] [Mr C] and his mother arrived".

Return to the clinic

Dr E recalled:

"[Ms B] arrived before 2100 [9pm] carrying [Mr C] over her
shoulder wrapped in a duvet cover. As she lay him down, it
was immediately obvious [Mr C] was septic, shocked and shut down,
with mottled blue/red skin discolouration and cool
peripheries. He was conscious but very drowsy. He was
still able to speak and try to be co-operative.

I immediately called to the receptionist for a 111 ambulance
(for a shocked child) and asked [Ms H] to draw up 600mg of Benzyl
Penicillin, while I inserted a 22 gauge IV cannula into the R
cubital fossa. I injected the Benzyl Penicillin, then [Ms H]
connected the Haemacel 250ml fluid bolus, by which time the 3
ambulance crew had arrived.

In a subsequent conversation with [Mr C's] mother, she told me
[Mr C] had not had the skin discolouration prior to coming
in. I have since visited [Mr C] in [a children's public
hospital] on two occasions as I was in [the city]."

Staff nurse Ms H recalled:

"… While we were in the room inserting the line and antibiotic,
the ambulance officers arrived. We transferred him to the
ambulance trolley at which time the ambulance officer inquired
about [Mr C's] blood pressure which I took immediately [30mmHg
systolic]. The patient was then transferred into the
ambulance. … "

The Ambulance Case Record states the ambulance was despatched at
9.13pm, arrived at the clinic three minutes later at 9.16pm, left
for a neighbouring public hospital at 9.25pm, and arrived there at
9.31pm.

Mr C was transferred from the public hospital to a children's
public hospital, but died on 21 April 2000 of complications of
meningococcal disease.

Meningococcal septicaemia is a systemic disease caused by the
presence of meningococcal bacteria in the blood and the effect of
the toxins on the body. Meningitis refers to an inflammation
of the meninges around the brain, and can be caused by either a
virus or bacterium. Meningitis may or may not be present in a
person infected with meningococcal bacteria.

File reviews

Dr F, Medical Director of the clinic, stated that meningococcal
septicaemia was "notoriously difficult to diagnose and definitive
signs often present last". Dr A also stated that "the
presenting clinical picture of meningococcal septicaemia is
notoriously misleading".

Dr F undertook an internal audit for the clinic of the care
provided to Mr C. Dr F reported these
findings to Dr A on 1 May 2000. Dr F stated in
conclusion:

"None of the review processes were able to identify any area
where the handling of this case could have been improved upon and
the rapid decline without any clinical signs of meningitis again
reflects the aggressiveness of this particular 'phage' type of
meningococcus. The Medical Officer of Health and paediatric
staff at [the public hospital] inform me that they are still no
closer to identifying that organism either."

Dr F also requested peer review of Mr C's file from general
practitioners Dr K, Dr L and Dr M. Dr A also requested that
his colleagues Dr I and Dr J from his general practice at […]
Medical Centre review Mr C's file, together with the statement from
Ms B.

In brief, Dr K, Dr L and Dr M found the management of the case
appropriate and the standard of care "good". The clinical
notes were good but the record keeping should have been
better. However, neither further action nor investigation was
warranted during the time Mr C was in the clinic on the afternoon
of 9 April 2000. On the other hand, Dr J and Dr I found that
the management at the initial presentation was "sub-optimal" in
several respects. These involved: the recording of vital
signs, the account taken of the mother's concerns, treatment with
paracetamol and Brufen, action required on suspicion of
meningococcal disease and the adequacy of safety netting.

All doctors had access to the clinical notes from the clinic,
but not to the full account of events from all parties directly
involved. Dr I had read the opinion of Dr J.

Independent advice to Commissioner

The following expert advice was obtained from an independent
general practitioner:

"SUMMARY OF EXPERT OPINION

[Dr D] appears to have made several errors of judgement:

seemingly failing to differentiate meningitis (from whatever
infective organism) from meningococcal septicaemia, and failing to
appreciate several clinical pointers to how sick [Mr C] was

underestimating the concerns / clinical acumen of [Ms B]

underestimating the severity of [Mr C's] illness.

However [Mr C] was observed for several hours and did seem to
improve with the medications he was given - his temp came down and
from all reports he seemed better. The explanation and
mitigation offered in [Dr F's] letter is correct - it is
notoriously difficult to diagnose and definitive signs often
present last. There is also extreme pressure on GPs to
refrain from admitting to hospital.

[Dr E] seems to have acted with a reasonable standard of care -
she only saw [Mr C] (during the first presentation) when he was
better - having responded to the medicines he was given. She
also acted with speed and acumen when he presented the second
time.

In response to your questions:

It seems likely that [Dr D's] care was slightly under the
acceptable standard - but it is a pretty marginal decision -
between a genuine mistake and incompetence.

It would be wise to compare this case to findings on other cases
involving meningitis and meningococcal disease (esp. meningococcal
septicaemia) before writing the opinion, this especially
considering the status of the complainant.

[Dr E's] standard of care was good.

The clinic does seem to have taken steps to review / externally
audit the actions of its doctors and this is commendable. I
don't have the results of this to see whether it is reasonably
objective.

Their record of diagnosis as outlined in [Dr F's] letter is
extremely impressive. So there does not seem to be general
incompetence or unawareness of the clinic as a whole.

FACTORS CONSIDERED IN REACHING OPINION

Meningococcal disease is notoriously difficult to diagnose and
treat as accurately outlined in the letter from [Dr F], Director
[of the clinic].

However there does seem to persist, throughout the
correspondence, confusion between Meningitis and disease from
Meningococcal infection - in [Mr C's] case meningococcal
septicaemia.

Meningococcal septicaemia does not have signs and symptoms of
meningitis, although meningococcal meningitis will do so.
This is pointed out in [Dr A's] letter.

Meningococcal septicaemia (meningococcemia) - produces the
sudden and rapid onset of headache spiking fever chills,
arthralgias and muscle pains, with racing pulse (tachycardia)
tachypnoea (rapid breathing) and often hypotension (low blood
pressure). The rash recognised as a diagnostic sign may
appear at about this time but may be, as in this case,
sparse. The doctors were apparently looking at a freckle on
[Mr C's] chest rather than the petechial spots in the axilla.

Vasoconstriction is also a feature - with pallor and cold
extremities although the patient is often alert (see attached
chapter from Harrison's Principles of Internal Medicine).

So certainly there were no signs of meningitis - but [Mr C]
didn't have meningitis.

Many of the 'soft' signs referred to by [Dr A] - esp. the look
in the eyes - can occur as a result of delirium from fever as well
as from meningococcal disease. It is not an accepted
sign. But such observations are part of the general
assessment of how sick the child looks. It's a bit of that
nebulous thing - clinical acumen. This increases with
experience in general practice.

[Dr D] did a lot of good things. He kept [Mr C] at the
clinic and observed him over some time from 13.20 to approx. 4pm
with an attempted discharge and didn't just bundle him on
out. He requested a second opinion before he OK'd [Mr C's]
discharge. He advised [Ms B] to re-present if there was
deterioration.

On the other hand some vital signs are not recorded particularly
pulse and respiration rates (although in many cases in general
practice such things are observed but not recorded). But a
child with a fever of 39.7 would probably have both tachycardia and
tachypnoea anyhow, irrespective of the cause of the infection.

[Mr C] seemed better after some paracetamol and ibuprofen (both
used to manage fever) but immediately outside the clinic he started
vomiting again. Although he was re-observed he was not
admitted. It is difficult to gauge whether hospitalisation
was discussed - [Dr D] says in his statement that he offered
hospitalisation - but this is not mentioned in any other of the
correspondence.

It is difficult being a City GP and commenting on management in
rural areas much further from hospital facilities. I should
however have thought that this isolation would increase caution,
particularly when dealing with sick children - whose illnesses tend
to become more acutely critical very rapidly. So much of the
diagnosis in this case rests on the acumen of the clinician - how
sick did this child look? Allied to this is how sick the
mother thinks the child is. The second assessment also
involves very complex judgements: how accurate an historian is the
mother, does she over or understate the problems, how observant is
she?

This can be extremely difficult in an emergency where the doctor
has no prior relationship - no way of validating either the
doctor's perception of the parent or the parent themselves.

Here the concerns of the mother - a trained health professional
- do rather seem to have been underestimated. Similarly the
severity of the sickness of the child was underestimated, the
illness costing [Mr C] his life, and we will never know if
treatment at this stage could have prevented this.

[Mr C's] family is an important consideration in how to
proceed. His mum is a nurse, his granddad a [retired]
GP. I wonder did [Dr D] know this at the time. Under
such circumstances most would err very much on the side of
caution. It is an important consideration in deciding this
complaint too ([Dr A] has written a letter to the NZMJ about the
clinical confusion between meningitis and meningococcal
septicaemia).

There is also a medico-political element of contention between
GPs and commercially based and run clinics such as [the clinic],
the doctors and others.

So is this incompetence or a very tragic mistake or a little
combination of both?

Probably a bit of both.

But I find it impossible to be conclusive on the basis of this
case alone. I would advise the Commissioner to review the
decisions of all the cases of complaint about meningitis /
meningococcal disease and see where this case fits among those
outcomes."

My advisor was provided with the following information about the
geographical relationship between the patient's residence, the
clinic, and the neighbouring public hospital, and was asked the
further questions set out below:

"1. [The clinic] is situated in […], where [Ms B]
travelled from is a small settlement […]. The drive from […]
usually takes approximately 20 to 30 minutes. [The public
hospital] would be within a few minutes' access from [the
clinic].

2. A review of other cases involving the diagnosis of
meningococcal disease would be unlikely to be helpful as a guide to
how this case should be judged as each case turns on its own
facts. From a medical point of view however please clarify if
it is impossible to be conclusive on the basis of this case
alone? The question is whether the service received by [Mr C]
was provided with reasonable care and skill? This is, as
discussed, ascertained in the usual manner by an assessment of what
a reasonably careful general practitioner, in those circumstances,
could reasonably be expected by his or her peers to have done.

3. Were the reasons for your summary comment that '[Dr
D's] care was slightly under the acceptable standard' that he
'[failed] to recognise clinical pointers'?

If so, what pointers? Was it only a failure to properly
estimate the concerns of the mother? In answer to your query
as to whether [Dr D] knew of [Ms B's] background; in [Ms B's]
statement (The Doctor's Visit) she states she told [Dr D] her
father was a GP who had diagnosed many cases of 'meningitis' and
also told him of the 'odd look in the eyes' that her father would
note.

Underestimating the child's illness? Was this comment from
the perspective of the time or a comment made with the wisdom of
hindsight? How, or in what actions or omissions, from the
perspective of the time did [Dr D] underestimate the child's
illness?

4. Both [Dr D] and [Dr E] looked at what was described by
[Ms B] as a small deep purple spot, resembling a flat skin stone
bruise, 2mm in diameter with a red halo, in the right ante cubital
fossa.

[Dr D] consulted a medical textbook and compared it to the spot
spoken of by [Ms B]. How does [Ms B's] description of the
spot compare with a meningococcal rash? [Dr D] called in a
second opinion from [Dr E], and [Ms B] said she showed them the
spot in the ante cubital fossa but they seemed concentrated on a
freckle on the chest. How do you interpret this? Were both
doctors not taking account of the mother or was the significance of
antecubital spot missed by both or was the spot possibly of no
clinical significance or something else? It is noted that
when the child re-presented that [Dr E] said she inserted the 22G
IV cannula for the benzyl penicillin and fluids into the right
cubital fossa. If a meningococcal spot had been present there
earlier in the afternoon, what would have happened to it over the
hours to re-presentation? Is it possible that [Dr E] would
not have noticed a spot of clinical significance in the antecubital
fossa if she was inserting an IV there? Is there a possible
confusion of the alleged facts?

5. How is it that [Dr E] gave a good standard of care when
she agreed with [Dr D] that the spot was not representative of the
rash typically described with meningococcal disease? What are
the duties and obligations of a doctor when asked for a second
opinion?

6. Was it reasonable to diagnose the child with a 'viral
illness' given his signs and symptoms? Was there any clinical
feature, and if so what, that reasonably should have triggered an
alert to a general practitioner of the underlying seriousness of
the child's condition?

7. You have stated there was confusion between meningitis
and meningococcal disease. Was this confusion on the part of
[Dr D] or [Dr E]? If so, what factors point to the
confusion?

8. You have said [Dr D] did a lot of good things and
listed them, but in the next paragraph you state 'on the other
hand' the pulse and respirations were not recorded before
concluding a child with a temperature of 39.7 would be tachycardic
and tachypnoeic irrespectively. What is the relative
importance of not recording the pulse, respirations and blood
pressure?

9. Are you saying in the report that there is no essential
difference between the 'look in the eye' of a child febrile with
the early stages of meningococcal disease and a child febrile from
any other cause?

10. Would it be usual practice to document an offer of
hospitalisation if made or made and refused?

11. You have stated that it is impossible to be conclusive
but have concluded [Dr D's] care was slightly below the
standard. Is it possible to clarify that position?"

My independent general practitioner advisor provided the
following additional advice in response to the above questions.

"1. Thank you for clarifying the geography. My
assumption of isolation was based in part on the actions of [Ms B]
(in taking [Mr C] to the clinic rather than directly to the
hospital).

I will come back to this in answering point 11.

3. As you say in your 3rd pointer
under this topic it is extremely difficult not to use hindsight in
this case.

If we consider the data [Dr D] had to work with: (I have taken
this from the [clinic] sheet and some information from [Ms B] and
the nurses' statements).

VERIFIABLE

There was a suddenly sick child - normally very healthy who
became sick about 2 hours earlier.

He was febrile (39.8).

He had vomited in reception.

He was probably 'floppy' and weak when the nurse was trying to
weigh him.

He responded to the paracetamol with reduction in temp and
improved wellbeing.

[Ms B] says he 'was conversant and the most awake he'd been for
hours' before he left the clinic.

ABSENT

Both parties agree there was no sign of meningitis (as accurate
assessment: no photophobia; no neck stiffness; [negative]
Kernig's).

The eye signs alluded to must be disregarded: it is not an
accepted clinical indicator. Certainly sick people get a
glassy vacant feverish stare but I do not know that this is
different for a septicaemia (or for that matter meningitis).

CONFLICTING DATA IS PRESENTED ABOUT:

Photophobia - [Ms B] says it was present, the record sheet says
it was not. [Dr E's] record at 1500 says it was not.

'Peripheral shutdown' - I am not sure what exactly is meant by
this. In her statement [Ms B] uses the term to describe that
[Mr C's] hands were cold, his feet coldish and his torso
warm. No comment is made about what happened to the hands and
feet once [Mr C] developed a fever. It is noted on [Dr E's]
record at 1500 - 'warm peripheries'.

The things not recorded that I feel should have been (the
clinical pointers):

The very rapid pulse was apparently neither verified nor
recorded.

It would seem that there was significant weakness (the
floppiness when [Mr C] was weighed, his inability to stand unaided)
that was not noted.

The clinic seems to have access to paediatric BP equipment -
(see the later notation in [Dr E's] page: BP 30/-) but it was not
done at the earlier consultation.

4. It seems to me from reading the 2 accounts
([the clinic] c.f. [Ms B]) that the doctors were looking at:

A 'light brown spot on the mid chest' - from [Dr E's] notes on
the chest.

Either they were looking at different things or one account is
inaccurate.

Surely [Ms B] would have seen and corrected them if they were
looking at the wrong thing?

Either way 1 small spot would not constitute a meningococcal
rash.

No I would not have thought it likely that [Dr E] would have
missed such a sign in the area she cannulated if it had been
apparent.

5. The duties and obligations of a doctor
asked for a second opinion are to frankly evaluate the information
presented and reach an independent diagnosis, which should then be
compared to the original doctor's ideas. Each should then
evaluate the 2 opinions, discuss as necessary and achieve a
consensus in the patient's interest. This seems to have
happened.

On the information present and presented it was reasonable to
diagnose a 'viral illness' given the signs and symptoms at
1-3pm. [Mr C] did seem to rally and settle as the fever
settled (documented) after the paracetamol. There are no
'hard' clinical features presented by either party to indicate the
seriousness of the illness.

If you read the highlighted segment on Meningococcaemia in the
Harrison's chapter,

'Patients usually appear acutely ill with an inordinate degree
of prostration.'

This is the soft, experience, judgement thing that it is
impossible to include in notes but will make the difference between
referring and possibly catching something like meningococcaemia
early enough to treat effectively, and not. Not
having/judging this however does not constitute negligence.
It is perhaps that certain something that will differentiate the
'really GUN' diagnosticians from competent ones.

'However clinical shock does not occur unless fulminent
meningococcaemia supervenes' - this would be the situation when [Dr
E] saw him at 9.40pm.

Both doctors and [Ms B] mention in their notes the absence of
neck stiffness, photophobia, Kernig's sign etc - all features of
meningitis. [Dr D] said that it was 'not meningitis, as I had
questioned it was'.

This is of course correct.

8. I think that a pulse of 162 would alarm
me. It is a bit too high for a viral fever. Taking the
BP, if it had been low in conjunction with the very high pulse may
have alerted to the possibility of a more serious illness e.g.
septicaemia. A very rapid shallow breathing rate would have
supported this concern i.e. some signs of 'inordinate
prostration'.

In an ordinary case of a viral illness, taking / recording these
things would be of no significance at all. It really comes
down to clinical congruence - does it all fit together?

The signs if abnormal could have other explanations (e.g. the
fever) but some lack of meshing could have triggered the 'well
perhaps we should admit, this doesn't feel quite right' bells we
all develop - but they are experience and judgement related.

9. We must disregard the 'eye signs' - they
are part of these same judgement triggers - but must be experienced
and cannot be taught. They are very 'soft' data.

10. One would document such an offer if you thought it
might be necessary (i.e. that medico-legal verification could be
necessary).

Or if you really thought the patient should be in hospital and
they refused.

Or if you had lots of time.

I do wish to revise this opinion.

If any signs were apparent, which cannot be inferred, they were
not missed through incompetence. [Dr D] exercised reasonable
care and judgement.

The 'soft' signs mentioned may or may not have been
present. If so both doctors missed them at the earlier
consultation but [Dr E] quickly recognised them at the
second. This does not seem likely. Meningococcaemia is
a really rotten rapidly progressing deceptive disease, which
changes quickly and is rapidly fatal. Its diagnosis is most
often extraordinarily difficult until it is very
obvious.

It was 5½ hours from the time he left the clinic until he
returned - a long time in the course of a meningococcaemia."

My advisor was asked if Pamol and Brufen syrup was a reasonable
treatment for a diagnosis of "probable viral illness". My
advisor responded in the affirmative, that used together Pamol and
Brufen syrup is an effective combination. My advisor was also
asked if a temperature decrease from 39.7 to 36.5 between 1.00pm
and 3.20pm could be expected. My advisor advised that this
degree of temperature drop in that timeframe was normal and could
be expected after the administration of Pamol and Brufen syrup.

Response to provisional opinion

The complainant, Dr A, submitted an extensive report dated 30
October 2001 in response to my provisional opinion. The
footnotes to Dr A's submission appear as an Appendix to this
opinion. Dr A stated as follows:

"I have received your provisional opinion dated 5 October 2001,
on my complaint against [the clinic] and [Dr D].

I disagree with your provisional opinion, and submit this letter
by way of response, on the basis of a misinterpretation of fact and
the evidence.

I record that this is an incomplete investigation and thereby an
incomplete provisional opinion as the complaint against [the
clinic] has never been addressed in your said opinion.

I also record that you have not provided a copy of the report
from [the clinic], which creates a difficulty in determining upon
what basis your opinion has been reached.

My response is set out under the following headings:

Failure to record vital signs

Failure to heed mother's concerns

Failure to diagnose

Failure of [the clinic] to formulate protocols in triage of
pyrexial children

1.1 (a) This is basic triage and should be a part of the routine
assessment of every sick child presenting with a pyrexia of unknown
origin, along with a history of the presenting illness and a review
of the child's medical and family history.i

1.1 (b) I note your opinion states previous cases involving
meningococcal disease are not useful as they all turn on the
facts.ii All cases do turn on their facts, however,
precedent does exist in the body of Health and Disability
Commissioner reports, where the advice of the Director … of Public
Health has been accepted, that it is incumbent on general
practitioners to take a full medical history to assist in deciding
whether a consumer is experiencing a viral (gastroenteric) illness
or a more serious illness.iii The failure to
undertake basic triage in my opinion is a failure to take a full
medical history. As you will be aware, that case resulted in a
recommendation to the Medical Council of New Zealand that the
general practitioner involved undergo a competence review.

1.2 [Dr D], I note, advised that observations
of these recordings (temperature, pulse, respiratory rate and blood
pressure) were not routinely taken at [the clinic] for every
febrile child.iv

1.3 The clinical story on presentation
was:

Sudden onset of illness

Fever 39.8

Tachycardia (noted by mother pulse 160 +)

Vomiting

Headache

Weakness - had to be carried and supported when being
weighed

Myalgia - right-sided pain as reported to the triage nurse

1.4 These are all classical signs of
meningococcal septicaemia.v vi

1.5 There was no baseline audit
undertaken, apart from temperature. Such basic triage would have
alerted [Dr D] to a more sinister illness than a viral infection.
This is substantiated by the comment of your independent medical
expert,

'I think that a pulse of 162 would alarm me. It is a bit too
high for a viral fever'.vii

1.6 Any reasonable physician faced with
this history, would have or should have been alerted to the
possibility of bacterial rather than viral infection with a
consequent change in the pattern of management, such as admission
to hospital with a throat swab, white blood count, blood culture
and administration of antibiotics.viii

1.7 Further, having read your
provisional report carefully I note that, despite your independent
expert advising some vital signs are not recorded,ix you
appear to approve of the failure of those involved to carry out
adequate triage. The inference being that basic recordings are not
essential. This is setting a precedent for a standard of service,
which will inevitably lead to further missed diagnoses such as
occurred in [Mr C's] case.

1.8 This failure to undertake basic
triage early in the consultation resulted in the error of
diagnosis. [Dr D] decided that he was dealing with a case of viral
infection, a diagnosis from which he did not budge.

1.9 In my opinion, the nurse doing the
original triage, [Dr D] and [the clinic] are all culpable in their
management of [Mr C's] illness. This is a breach of Right 4 of the
Code of Health and Disability Services Consumers' Rights.

2.0 Failure to heed mother's concerns

2.1 [Dr D] failed to heed the concerns
of [Mr C's] mother ('[Ms B]') in regard to more than one clinical
sign of pyrexia of unknown origin.

2.2 Parental knowledge

He ascertained she was a trained nurse, her father a recently
retired General Practitioner, that she had discussed meningococcal
disease [meningitis] with him and recalled the so-called 'eye'
signs, that the child looked through you rather than at you.

2.3 We would ask you to further note
that [Ms B] has [very close associations with three doctors,
including a paediatrician]. She has [also] nursed in […]
hospitals. [Dr D] was aware [Ms B] was a nurse.

2.4 This all leads to the conclusion
that she had a certain level of knowledge that lay members of the
public may not possess.

2.5 Furthermore, she had left her other
3 children in the care of [Mr C's] friend's mother who was a
complete stranger to her, while she took [Mr C] to [the clinic], a
30 minute car journey. This geographical isolation in a rural area,
along with the high incidence of meningococcal disease in the
locale, is relevant in erring on the side of caution with treatment
and monitoring.

2.6 Your
independent GP advisor seemingly also held this viewpoint in his
initial opinion,

'[Mr C's] family is an important consideration on how to
proceed. His mum a nurse, his granddad a [retired] GP. Under such
circumstances most would err very much on the side of
caution'x

2.7 There are many papers on
Meningococcal Disease.xi All point out:

That we must have a high index of suspicion for the
condition

That we must take note of the concerns of the parents

That we must be meticulous in our search for a rash

That we give antibiotics sooner rather than later

2.8 Meningococcal rash

When [Ms B] alerted [Dr D] to the petechial spot on [Mr C's]
right arm in the ante-cubital fossa, he took out a medical textbook
and showed her what an advanced meningococcal rash looked like. A
recent studyxii conducted on 126 children with
meningococcal disease, showed that parents or relatives were the
first to spot a petechial rash in 92 cases. This study highlighted
the need to emphasise in information for practitioners and parents
the septicaemic rash, not meningitis.

2.9 [Dr D] who, when he sought a second
opinion from his colleague, Dr E focussed on a freckle-like spot on
[Mr C's] chest and dismissed this petechial spot on his right
ante-cubital fossa. This is recorded in Dr E's
notes.xiii

2.10 Both your medical expert and [Dr D]
appear to be confused as to what constitutes a petechial rash. The
expert dismisses the possibility of a single spot constituting a
petechial rash, and [Dr D] produces a textbook picture of a gross
purple rash with blood blisters (i.e. advanced stage meningococcal
disease, not dissimilar to that pictured in Ministry of Health
guidelinesxiv).

2.11 Your medical expert, I consider, is
at fault in dismissing this with a somewhat cavalier attitude when
he says,

'either way 1 small spot would not constitute a meningococcal
rash'.xv

2.12 The rash in meningococcal disease
may present in many ways, as maculopapular, petechial, purpuric or
other.xvi In other words, your medical expert is
incorrect, and one spot can constitute a petechial rash.

2.13 As an example of a parent correctly
being concerned is a mother's description of a single spot that
saved her baby's life. This child was in [a children's public
hospital] with [Mr C].xvii

2.14 Clinical research vindicates this
position.xviii The child must be stripped completely
when searching for petechial spots and also mucous surfaces such as
the palpebral conjunctiva, as important lesions can be
missed.xix

2.15 [Mr C] was not stripped at any time and his
mother does not recall his conjunctival surfaces being examined at
any time during the consultation.

2.16 Pulse rate

[Dr D] discounted [Mr C's] reported pulse of 162, (as recorded
by [Ms B]), as he failed to verify it and he further failed to get
a nurse to take or record [Mr C's] pulse.

2.17 [Dr D] indicts himself through his own admission that
it is 'difficult to count a pulse of 140, yet alone
162',xx and he failed to look for any septicaemic
process, any bacterial infection or any other reason for [Mr C's]
sudden onset of illness, apart from his misdiagnosis of 'probable
viral illness'.xxi

2.18 The 'eye signs'

[Dr D] failed to look at [Mr C's] eyes, when his mother
expressed her concerns. I note that your medical expert states it
is a 'soft' sign and is not an accepted sign.xxii I
disagree with this statement and would refer you and your advisor
to a recent study that found 'poor eye contact' as one reason to be
alerted to a possible meningococcal disease
symptom.xxiii

2.19 The responsibility of [the clinic] doctors,
having no previous relationship with the mother and having to make
a judgement about the quality of her parenting and her ability to
be a good historian, places an even greater responsibility on
doctors' shoulders.

2.20 Your expert alludes to this in his
opinion.xxiv

2.21 Regarding the question of hospital admission,
[Ms B] is quite definite that it was not offered. Further, this
offer was not documented and in light of [Ms B's] clear concerns
for her son, such an offer is unlikely to have been refused. In
light of what I see as [Dr D's] failings, I cannot accept his
statement.

2.22 Despite all this, [Dr D] chose to
ignore [Ms B's] concerns leaving her disempowered and forced to
accept his diagnosis of viral infection. I would argue that a
practitioner who takes a textbook and shows the mother a gross
purple rash with blood blisters, is in breach of Clause 1.1 of The
Code of Health and Disability Services Consumers' Rights.

3.0 Failure to
diagnose

3.1 [Dr D] made an initial diagnosis of
probable viral infection and never really waived from it, this
despite the mother raising the question of Meningococcal Disease
[meningitis].

3.2 Using Ministry of Health guidelines,
1998:xxv

3.2.1 Have a high index of suspicion for
meningococcal disease

3.2.2 Check all skin areas for the presence of
a rash

3.2.3 Accurately assess the severity of
illness and ensure treatment

3.2.4 Be aware of the febrile child - suspect
meningococcal disease

3.2.5 As part of the diagnostic process, the question must
be asked; did he really consider the mother's concerns?

3.3 There was a clear failure to turn
his mind to the septicaemic process and therefore [Dr D] lacked any
high index of suspicion.

3.4 [Dr D] failed to thoroughly check
[Mr C's] body for any sign of a rash and discounted [Ms B's]
concern in regard to the petechial spot on the ante-cubital fossa
at the 15.00 hours consultation.

3.5 [Dr D] failed to accurately assess
the severity of the illness through the failure to undertake basic
triage. Verification of [Ms B's] assessment of the pulse rate of
162 may have alerted the doctor to a bacterial rather than viral
infection. Failure to investigate urine output, failure to
investigate any tachypnoea (high respiration rate) and failure to
understand the significance of staring (eye signs) would have
alerted [Dr D] to the severity of the illness.xxvi

3.6 [Dr D] treated Mr C with Pamol and
Brufen. Pamol will reduce temperature and Brufen will mask the
clinical signs of any bacterial infection. It follows that his
temperature would reduce, which is what happened when [Dr E] gave
her second opinion at approximately 15.00 hours.

3.7 For the reasons stated herein and
under paragraphs 1.0 & 2.0 of this response, there was a clear
failure to diagnose on [Mr C's] first presentation.

3.8 This failure to diagnose in my
opinion is a breach of Right 4 of The Code of Health and Disability
Services Consumers' Rights.

4.0 Failure of [the
clinic] to formulate protocols in triage of pyrexial
children

4.1 [Dr D]
advised that observations of temperature, pulse, respiration and
blood pressure are not routinely taken at [the clinic] for every
febrile child.xxvii

4.2 Your independent medical advisor
notes,

'I think that a pulse of 162 would alarm me. It is a bit too
high for a viral fever. Taking the BP, if it had been low in
conjunction with the very high pulse may have alerted to the
possibility of a more serious illness e.g.
septicaemia'.xxviii

4.3 The medical research supplied with
this response, in particular, Red Flags in Common
Pediatric Symptomsxxix clearly indicate
basic measures to take in clinical practice.

4.4 It is a reasonable expectation of
the public that their doctor, however recently acquainted with the
patient, will provide a level of care and skill in their service
that is of a reasonable standard.

4.5 It is reasonable to expect the
health service provider, in this instance [the clinic], to regulate
performance of its staff through appropriate training and other
methods including service protocols, induction into New Zealand
culture and knowledge from senior practitioners on local
conditions.

4.6 The second opinion provided by [Dr
E] at 15.00 hours was not that of a senior practitioner. If [Dr D]
had uncertainty of his diagnosis of viral infection, reasonableness
would dictate that he sought the opinion of a paediatrician or
physician. This is recommended practice by the Medical Officer of
[the district health board].xxx

4.7 This failure of [the clinic] to have
adequate protocols in place, both in terms of basic triage and
appropriate second opinions clearly contributed to the misdiagnosis
by [Dr D].

4.8 Such failures on the part of [the
clinic] is clearly a breach of Right 4 of The Code of Health and
Disability Services Consumers' Rights.

5.0 Interpretation of
independent medical expert's opinion

5.1 I am retired from General Practice
and was retired at the time of [Mr C's] illness and subsequent
death.

5.2 I have no proprietary interest in
[the medical centre Dr A worked for]. I am in no way influenced by
what I may have to say about my colleagues or they about me.

5.3 As noted earlier in this response,
the reports supplied by [Dr F] of [the clinic] from [Dr K, Dr M and
Dr L] are not available for my perusal. It is my understanding that
Doctors [M and L] hold directorships in [the clinic] and its
shareholding entity […], respectively. This raises the question of
their impartiality.

5.4 I have always seen myself as the
patient's advocate. The profession is notorious for protecting its
own. Now as an older and retired general practitioner I have no
hesitation in speaking out on behalf of the patient. In my mind,
your provisional opinion not only shows how the profession supports
its own, but it endorses their stance of cronyism to the detriment
of the user of the service.

5.5 Medico-Politics

Your independent GP advisor remarks about:

'a medico-political contention between GPs and commercially
based and run clinics such as [the clinic] …' xxxi

This may be relevant to your independent advisor as a city GP,
however, I note that the [the medical centre Dr A worked for] is a
24-hour service that is not in competition with [the clinic] on
either a geographical or patient basis. I question the relevance of
the expert raising this as an issue. Unless, he was under the
impression, that I was a practising local GP and that I was
antagonistic to [medical centres].

5.6 Soft signs

The 'soft signs' your independent medical expert dismisses will
not appear in Harrison's or any other standard book of Medicine. It
takes many years before advances in
knowledge reach standard textbooks. The single volume of Harrison's
that was available as the latest edition in April 2000 was already
two years old (i.e. published in 1998). Harrison's is a general
medical text, not a paediatric specific textbook.

5.7 There is surely a burden of
responsibility on a doctor to stay current of existing trends,
particularly where New Zealand is seen as being in the midst of an
epidemic. I do not believe that Harrison's is totally adequate in
this paediatric case.

5.8 The eye signs have been recognised
as looking through you rather than at you. The only other similar
case seen by me was a young sixteen-year-old suffering from Toxic
Shock Syndrome. These eye signs have been recognised by the
partners at [the medical centre Dr A worked for] for some years. My
letter to the editor of the New Zealand Medical Journal last year
brought confirmatory reports from other general practitioners
within New Zealand. 'Staring' is noted as a symptom in
research.xxxii

5.9 Peripheral Shutdown

Your medical expert when talking of peripheral shutdown,

'… I am not sure what exactly is meant by this'.

I do not understand his confusion, as this is a standard medical
term. Further on he states,

'… [Dr E's] record at 15.00hrs - "warm peripheries"
'.xxxiii

He does not appear to take any note of [Dr E's] description of
[Mr C's] presentation at 21.00 hours when [Dr E] recognised and
noted that,

The description appears a little similar to that given by [Ms B]
of peripheral shutdown at 11.00 hours. These signs are documented
on www.meningitis.org, specifically at web page
http://www.meningitis.org/frame1b.html.

5.10 Both [Ms B] and [Dr E] have respectively
described sets of symptoms clearly defined by the Meningitis
Research Foundationxxxv for the early (at 11.00 hours)
and late stages (at 21.00 hours) of this disease process.

5.11 Peripheral shutdown was described clearly by
[Ms B],

'… hands cold, torso warm but not hot … and feet
coldish'.xxxvi

This was with the onset of fever. As she is a trained health
professional her evidence must be accepted as clinical evidence
supporting the diagnosis as a bacterial rather than viral
infection. Again, I refer you to
www.meningitis.org.

5.12 It is noted that two or so hours later
following administration of Brufen and Paracetamol, [Dr E] states
that [Mr C's] peripheries were warm. This is to be expected
due to the effects of the anti-inflammatory and anti-febrile drugs
administered and in no way reduces the observations of [Ms B] at
approximately 11.00 hours that morning.

5.13 I cannot agree with the use of Brufen in a
patient who is vomiting. It is an anti-prostaglandin and may have
an adverse effect in some infections.

5.14 I note you questioned your medical
expert, if a meningeal spot had been present there earlier in the
afternoon is it possible that [Dr E] would have missed seeing it at
the second presentation when inserting an IV line. In the urgency
of the moment a shocked child with collapsed veins and blue
mottling of the skin, it would be quite likely that a small
petechial spot would not be noted. Further she had already looked
at this area earlier with [Dr D] and they had elected to ignore
it.

5.15 Your medical expert in discussing
meningeal spots and rashes makes no mention of the need to strip
the child completely to make sure that no spots are missed and he
makes no mention of the need to examine conjunctival and mucosal
surfaces. This is in direct conflict with Ministry of Health
guidelines 1998.xxxvii

5.16 What has impressed me all along is
the degree of confusion in the minds of the medical people and the
public about meningococcal disease and meningitis. This is
highlighted in your medical expert's initial
report:xxxviii

'[Dr D] appears to have made several errors of judgement:
seemingly failing to differentiate meningitis (from whatever
infective organism) from meningococcal septicaemia, and failing to
appreciate several clinical pointers to how sick [Mr C] was,
underestimating the concerns / clinical acumen of [Ms B],
underestimating the severity of [Mr C's] illness.'

5.17 Quite apart from the confusion about
meningococcal disease and meningitis, the medical expert appears to
believe that it was acceptable to seek a second opinion on this
very sick child from a similarly and relatively inexperienced
general practitioner, rather than phoning the hospital for a verbal
second opinion, from a paediatrician as general practitioners have
been encouraged to do.xxxix

5.18 Due care and exclusion of meningitis

Your medical expert says that,xi

'[Dr D] did a lot of good things. He kept [Mr C] at the clinic
and observed him over some time from about 13.20 to approx.
4pm'.

He goes on to state,

'On the other hand some vital signs are not recorded.'

Keeping the child in for observation showed that [the clinic]
was concerned, however, I do not agree that they showed due care.
It was too late. The mistake had already been made. Two health
professionals, staff nurse [Ms G], and [Dr D] had failed in their
responsibilities to the child. As a result a delay of some hours
occurred allowing progression of the disease process to its final
disastrous state.

5.19 Offer of hospital admission

With respect to the offer of hospital admission [Ms B] is quite
definite that it was not offered and in light of what I see as [Dr
D's] failings I cannot accept his statement, and believe that his
lack of documentation speaks for itself.

5.20 City general practitioner

To use a city general practitioner to provide independent advice
on the situation must be questioned. He is not conversant with
rural practice conditions or with a community where almost everyone
has known someone who has had experience of meningococcal disease.
Your medical expert comments on this difficulty,

'… and commenting on management in rural areas much further from
hospital facilities. I should however have thought that this
isolation would increase caution, particularly when dealing with
sick children, whose illnesses tend to become more acutely critical
rapidly'.xli

He asks,

'How sick did this child look?

Allied to this is how sick did the mother think the child is?'
xlii

He continues saying,

'… the concerns of the mother - a trained health professional -
do rather appear to be underestimated. Similarly, the severity of
the sickness of the child was underestimated, the illness costing
[Mr C] his life and we will never know if treatment at this stage
could have prevented this.'xliii

5.20 In conclusion, it is my opinion
that the independent medical expert has erred in his / her
judgement.

6.0
Summary

I cannot agree with your conclusions.

6.1 It is my
firm opinion that [the clinic] and its staff (Staff Nurse [Ms G]
and [Dr D]) failed in its duty to [Mr C].

6.2 The failure
to, record history in detail, monitor temperature, pulse,
respiration and blood pressure, respond to the concerns of the
mother and such lack of basic triage, I consider to be responsible
for the failure to diagnose. I question the validity of a 'normal
cardiovascular system and normal central nervous system' as
recorded in [Mr C's] [the clinic] notes, in the absence of this
baseline data (temperature, pulse rate, respiratory and blood
pressure).

6.3 If reasonable protocols were in
place, the nurse doing initial assessment would have noted, not
only temperature, but also pulse, respiratory rate and blood
pressure.

6.4 This should
have raised the suspicion in the mind of the doctor as to the
possibility of bacterial rather than viral infection.

6.5 It was this
failure early in the consultation that led ultimately to the final
outcome.

6.6 All the
doctors concerned, other than Doctors [J] and [I], accept that it
is not necessary to do basic recording. Your independent medical
expert goes along with this view although his thinking appears a
little confused and contradictory and the Commissioner supports his
view. If all health professionals follow this line of thinking,
further cases of meningococcal and other septicaemic infection will
be missed with subsequent morbidity and mortality.

6.7 In our
initial complaint we expressed our concern regarding the standards
in [medical centres]; this point has not been considered or
answered in your provisional opinion.

6.8 There was
failure to note and act on parental concerns.

6.9 There was
failure to recognise the seriousness of [Mr C's] illness.

6.10 There was an obvious lack of
knowledge of the meningococcal septicaemic disease process. I note
that the doctors were fixated on meningitis, namely neck stiffness,
Kernig's sign and photophobia.

6.11 An observation period of two plus
hours where recordings were only of temperature. To quote your
expert,

'at least they didn't just bundle him on out'.
xliv

[Dr D] only suggested that he stay around town for a while. Such
an extended observation period rendered no value in the absence of
other clinical measurements.

6.12 We have asked [Professor G, a
medical professor at a New Zealand medical school] to give an
opinion on your report and his report will come with this
expression of our view of your provisional opinion. This is
attached …

6.13 If the Commissioner accepts that it is not
necessary for doctors to undertake basic recording of vital signs,
we are concerned at the precedent that this would set. It is
foreseeable that a doctor facing a similar complaint may raise a
defence that the Health and Disability Commissioner has approved of
the practice of not monitoring or recording basic data such as
temperature, pulse, respiratory rate and blood pressure.

7.0 Outcomes sought

7.1 I would ask
that you request the Ministry of Health to lay down national
protocols for the triage of febrile children.

7.2 I would ask
that you request the Ministry of Health to further the education of
health professionals, especially in light of the confusion that is
apparent when diagnosis between meningitis and meningococcal
disease has to be considered. I would suggest that particular
attention be shown to the education of practice nurses, as they are
the front line contact for patients.

7.3 I would ask
that you draw attention of the New Zealand Medical Council to the
problems that are faced by doctors working in Accident and Medical
Centres. Many will be young doctors working under 'general
oversight' by vocationally registered doctors. Special skills will
be needed, as they will have to deal with patients that are unknown
to them and that have no previous medical records available.

Special courses, such as the Paediatric Emergency Programme, now
run by [ ] and the paediatric department at [the public
hospital] will help ensure that basic knowledge and skills are
developed and updated in tandem with on the job experience."

Professor G provided me with a copy of the following report
prepared by him for Dr A after reviewing my provisional
opinion:

"I am in receipt of your letter dated 12th October 2001 and your
request for me to review the Health and Disability Commissioner's
provisional report and other documents associated with the
complaint made against [the clinic] and [Dr D], regarding the
management of the illness of [Mr C].

I received from you a copy of the report from the HDC, copies of
various correspondence and hospital notes from [the children's
public hospital]. I met with [Ms B] and [her husband] on Wednesday
17th October.

Firstly, I am very sorry to learn of [Mr C's] passing and the
circumstances surrounding, and offer you my very sincere
condolences.

My understanding is that you do not accept the findings of the
HDC, in particular feel that the doctors should not have missed the
diagnosis and that if earlier action had been taken that [Mr C]
would still be alive today.

I have reviewed the various case notes and the HDC Provisional
Report and it appears to me that there are two salient points in
regard to the diagnosis of [Mr C's] condition.

The first relates to the first visit where the history as
recorded in the notes, and confirmed by yourselves is that [Mr C]
was quite sick, was not mentating normally, and had mild
photophobia. Importantly, [Ms B] noted that he was in
mild shock, with peripheral shutdown. While
adequate baseline observations were not taken, it is apparent from
the history that the peripheries were cold. The young child was in
fact sicker than was identified by the doctors.

The second point relates to the rash identified in the
antecubital fossa, recorded as petechial in the GP and hospital
notes. There is no record in the GP Notes that the patient was then
undressed and a full body examination conducted. It is possible
that a more detailed examination, called for at this point, may
have revealed further lesions and enabled an earlier
diagnosis. I further note that both of you as parents were
raising the possibility of 'meningococcal meningitis' as a
diagnosis because [Mr C] was quite sick. This should also have
alerted the doctors to a fuller examination.

You have related to me your concerns regarding to the attitude
of [Dr D], who you described as having a closed attitude, and that
he failed to take adequate notice of your concerns, both as
parents, and particularly also given that [Ms B] is a registered
nurse.

In my view, the doctors at the [the clinic] failed to recognize
how sick [Mr C] was at the first visit, from the point of view of
the history (and related parental observations and concerns in
regard to his sickness), and from the peripheral shutdown/shock. In
addition, it appears that they failed to do an adequate skin and
body examination to exclude the presence of other petechial rashes
elsewhere, at the first visit. There is very good evidence in the
hospital notes of widespread rash, which if present and diagnosed
earlier would have led to a different outcome.

At our meeting, as we discussed the case diagnosis and
management through, it became apparent to me that while there was a
very unfortunate outcome, that you both wish that something can be
learned from this case, both by the doctors, Clinic and general
practitioners in general (not all of whom should be considered in
the same category, of course).

My understanding is that your concerns would be recognised
by:

1. The Health and Disability Commissioner
changing the findings of the Report whilst recognizing the
difficulties and challenges that this case presented, to find that
the doctors failed to properly recognize that [Mr C] was sick, with
probable meningococcaemia on the basis of history, fever,
photophobia, peripheral shutdown/shock, and petechial rash (of
which there may have been more, if examined carefully).

2. An opportunity be given to yourselves to
meet the doctors and for you to express your concerns directly in
regard to the diagnosis and management of [Mr C's] condition and
attitude towards yourselves, that they may learn from the
event.

That the [the clinic] review their current practice of
employing relatively junior doctors, possibly with inadequate
training and experience for this role, and that an education
programme be put in place, at the clinic. In particular, you would
like to see [Dr D] undergo some form of appropriate postgraduate
education.

That, without prejudice, you do not wish this case to proceed
to the Medical Council of New Zealand, provided your concerns are
addressed.

After due and proper consideration, I believe that your concerns
are fair and will therefore copy this letter to the Health and
Disability Commissioner."

Additional independent advice to Commissioner

In light of the response to my provisional opinion, I sought
additional independent expert advice from a rural general
practitioner, Dr Tessa Turnbull. Dr Turnbull was provided
with all relevant material, including my provisional opinion, the
response from Dr A, and the report from Professor G. Dr
Turnbull provided the following advice:

"Background:

Four year old [Mr C] became suddenly and progressively ill on
9/4/00. His mother is a RN and was particularly concerned
about his sudden lethargy, warm body but coldish hands and
feet. She took him to [the clinic] just after 1p.m. where he
vomited on arrival.

He was seen promptly, his temperature was 39.8, he was examined
by [Dr D] and given medication (paracetamol and brufen) to bring
the temperature down. He was monitored regularly while there
for 2-3 hours. The diagnosis of meningitis was raised but
rejected by [Dr D]. A small red/purple spot was noted on the
right arm by [Mr C's] mother and pointed out to [Dr D].

[Mr C] vomited on leaving the clinic and was re-examined by [Dr
E] with [Dr D]. They appear to have concentrated on a freckle
on his chest and both checked for signs of meningitis, which were
absent.

[Dr D] said he offered to arrange a hospital admission for
monitoring but said [Mr C's] mother felt able to do this
herself. [Ms B] disputes this and says admission was not
offered. [Mr C's] condition had improved somewhat and he was
apyrexial at that stage.

[Mr C] continued to vomit at home and his general health
worsened so he was returned to the clinic at 9pm, shock recognised,
resuscitation begun and transfer to [a children's public hospital]
initiated.

Assess and comment on the information and medical
literature supplied in response to the Commissioner's Provisional
Opinion by the complainant [Dr A].

[Dr A] has provided a dossier of papers and other material to
support his disagreement with the Commissioner's provisional
opinion in his complaint against [the clinic], [Dr D] and [Dr
E].

In applying, or referencing, this material to the Commissioner's
Provisional Opinion, it is important to realise that much of the
material is educational. This means that doctors assessing
young children in an ordinary or emergency situation should have
this material, or something similar, at their fingertips or within
easy reference.

Some of the papers are important, as they help us test [Dr D]
and [Dr E's] performance against their peers.

Report on Opinion - Case 98HDC15681

A fatal case of rotavirus gastro-enteritis and meningococcal
septicaemia in a young child. The child had symptoms of
gastro-enteritis for several days, leading to dehydration. He
then developed progressive meningococcal disease. A telephone
consultation occurred late at night between the GP and the child's
grandmother during which the GP, who had been away from his
practice for the first part of the child's illness, failed to take
a complete medical history. This meant the child was not seen
for several hours by which time the meningococcal septicaemia was
well established. The Commissioner ruled that the GP was in
breach of Right 4(2) of the Code of Health and Disability Services
Consumers' Rights in failing to obtain an adequate medical history
at the first telephone consultation. The GP was required to
apologise in writing to the consumer's whanau and familiarise
himself with appropriate legislation that would have helped him
manage this case better.

The rural GP has changed his practice as a result of the case to
one of extreme caution in dealing with sick children in out of
hours situations.

My Comment:

This case bears some similarities to that of [Mr C] in that both
concern fatal meningococcal septicaemia. However, this
complaint relates partly to a telephone consultation during which
an incomplete history was elicited.

Meningococcal Meningitis and Septicaemia Diagnosis and
Treatment in General Practice

Meningitis Research Foundation United Kingdom

This is a useful guide, which reiterates that meningococcal
disease is uncommon but important because of its serious
nature. Septicaemia is more likely to be fatal when it occurs
without meningitis. A patient with septicaemia may present
with very different symptoms from someone with meningitis.

During the early, prodromal stage of the disease a patient may
present with a non-specific febrile illness that is not always
possible to distinguish from influenza or other viruses.
Since the disease can progress so rapidly, it is important, subject
to the GP's clinical judgement, that a patient, or parents of a
patient, with a non-specific illness who is not being sent to
hospital is given:

reassurance to trust their instincts and encouragement to seek
immediate medical help again if the patient's condition
deteriorates

information about the signs and symptoms of serious
illness

a description of both a typical meningococcal rash and the
'Tumbler Test'

The symptoms and signs of the disease are described as a rash
anywhere on the body, tachycardia, tachypnoea, cyanosis, cold hands
and feet due to poor capillary refill, rigors, oliguria,
joint/muscle pain, abdominal pain, drowsiness/impaired
consciousness (a late sign in children), hypotension (a very late,
pre-terminal sign in children).

Bacteraemia in febrile children presenting to a
paediatric emergency department i.e. the Royal Children's Hospital,
Melbourne.

Conclusions:

'Most urban Australian children aged 3-36 months presenting to a
paediatric emergency department with temperatures over 39 degrees
without a clinical focus have a viral infection. However,
3-4% have occult bacteraemia. Neither the clinical features
nor a high White Cell Count reliably identify these patients.
As empirical antibiotics may contribute to increasing antibiotic
resistance and have not been shown to prevent the rare complication
of meningitis, we believe that close contact and regular review of
these patients is preferable to empiric antibiotic therapy.'

Practice Guidelines for the management of Infants and
Children 0-36 months with fever without Source.

Developed by the UCLA Emergency Medicine Centre, Los Angeles
from a comprehensive literature search by an expert panel of senior
academics with expertise in paediatrics and infectious medicine or
emergency medicine.

This was a study to develop guidelines for the care of infants
and small children who are assessed in doctors' offices and
emergency departments with a fever but without an obvious source of
infection.

A child who is described as being 'toxic' is defined as having a
clinical picture consistent with the sepsis syndrome i.e. lethargy,
signs of poor perfusion, or marked hypoventilation,
hyperventilation, or cyanosis. Lethargy is defined as a level
of consciousness characterised by poor or absent eye contact or the
failure of a child to recognise parents or to interact with persons
or objects in the environment.

Conclusion:

These guidelines do not eliminate all risk or strictly confine
antibiotic treatment to children likely to have occult
bacteraemia. Physicians may individualise therapy based on
clinical circumstances or adopt a variation of these guidelines
based on clinical interpretation of the evidence.

My Comment:

The study and subsequent guideline development is American
based, involves very young children only, and is dependent on
having rapid access to a WCC. In addition, as with all
guidelines, they have to be accepted, actively adopted and utilised
by practising physicians.

BMJ Education and debate 16/11/1996

Lesson of the Week: Who spots the spots? Diagnosis
and Treatment of early meningococcal disease in
children.

A prospective study of children admitted to four Merseyside
hospitals with meningococcal disease over 18 months together with a
case study of missed diagnosis, which led to the child's death.

Conclusions:

The information widely available (about meningococcal disease)
may be misleading because it tends to focus on meningitis rather
than septicaemia.

The first doctor to see a child with meningococcal disease
needs 'knowledge out of proportion to their previous
experience'. GPs and casualty officers need to be taught to
recognise the rashes of meningococcal septicaemia and to give 'on
the spot' penicillin and not to delay treatment by looking for
signs of meningitis.

The rashes of meningococcal disease may be maculopapular,
purpuric, or petechial or there may be no rash.

83 cases of meningococcal disease in children and teenagers
under 16 were identified using hospital morbidity data. 31
children were selected by purposive sampling to get a
representative group. These children were referred by 26 GPs
who were interviewed using semistructured audiotaped
interviews.

Objectives:

To describe the presentation of meningococcal disease in primary
care; to explore how GPs process clinical and contextual
information in children with meningococcal disease; and to describe
how this information affects management.

Conclusions:

The key clinical feature of meningococcal disease, a
haemorrhagic rash, was present in only half the study
children.

The GPs specifically hunted for the rash in some ill children
but doctors should not be deterred from diagnosing meningococcal
disease and starting antibiotic treatment if the child is otherwise
well, if the rash has an unusual or scanty distribution, or if the
rash is non-haemorrhagic.

The GPs noted abnormal illnesses with features different from
those of acute self-limiting illnesses including unwillingness to
interact or make eye contact, altered mental states and pallor with
high temperature.

Knowledge of patients and their help seeking behaviour were
important in making management decisions.

Prompt treatment requires early recognition but in up to a
quarter of cases the diagnosis is delayed by more than 48 hrs after
the onset of the illness.

Abnormal features not expected in children with acute
self-limiting febrile illness were:

1. abnormal lethargy, some children were
described as almost motionless and not wanting to be moved.

2. 3 children seemed to be vacant and did not
make eye contact or interact with their parents or the GP.

3. 5 children had altered mental states i.e. 2
were confused, 2 were behaving abnormally and one was comatose. 3
children had abnormal cries, 5 were pale and 3 were cyanosed.

4. Unusual or puzzling findings were described
in 9 children e.g. pallor, hot but not red, crying when handled,
joint pain.

The role of parents was perceived by GPs as being very
important in decision making about management - in particular,
taking account of perceived level of parental anxiety about their
child's condition.

My Comment:

This is an important study as most papers emanate from hospitals
where meningococcal disease is seen at a late stage.

The spectrum of meningococcal disease varies from self-limiting
benign meningococcaemia to fulminant septicaemia. Specific
signs and symptoms that enable a doctor to make a certain early
diagnosis have not been identified.

Study Objectives:

To review the signs and symptoms in children diagnosed with
meningococcal infection; to assess age, sex and race distribution
of meningococcal infection; and to assess associations of the
presenting features with morbidity and mortality.

This is a retrospective study of children documented to have
meningococcal disease between 1990-95 presenting to the Princess
Margaret Hospital for Children in Perth. If the initial
presentation was to a GP or a peripheral hospital, the data from
the first presentation was documented.

Conclusions:

62% of children had a rash on presentation. The
maculopapular rash of meningococcaemia was mistaken for Henoch
Schonlein purpura on one occasion, for varicella on two occasions
and a non-specific viral illness on three occasions. These
children were all sent home and subsequently readmitted either
because their condition deteriorated clinically or because
specimens collected at the time of their initial presentation
returned positive for N meningococcus.

An incorrect initial diagnosis was made in 17.1% of
patients. Two of these were referred from other
hospitals.

No features present on the initial presentation were identified
which would expedite the diagnosis.

59% (62) of patients had their BP recorded on
presentation. The systolic BP was elevated in 6 and decreased
in 6. The diastolic BP was elevated in 4 and decreased in
11. 3 patients had an unrecordable BP.

Mortality was 8.6% and mortality and morbidity in cases with
meningococcal septicaemia was higher in comparison with cases of
meningitis alone or meningitis/septicaemia.

Fever and tachypnoea were the most common presenting features
followed by vomiting and irritability.

Rash was a feature in 59% of patients. The rash was
absent on the initial presentation in 8 patients and did not become
apparent until later in the illness. This reinforces the
importance of frequently re-evaluating children in whom a diagnosis
is unclear.

Photophobia and headache were found in only 5 and 8 patients
respectively. The number of children who were initially
misdiagnosed (17.1%) and sent home (5.7%) is evidence that an early
clinical diagnosis is often difficult and a very high index of
suspicion is necessary.

There needs to be a low threshold for making a presumptive
diagnosis and commencing treatment. In addition to the
described difficulties in making a timely diagnosis, atypical
presentations seems to be increasingly common.

The study identified important prognostic factors: hypotension
and purpura at presentation, age, septicaemia rather than
meningitis and delayed diagnosis.

Many studies of sepsis have shown a correlation between a low
BP and death or reduced systolic BP and death. There have
been no studies indicating that a low BP is predictive. A
decreased diastolic BP generally is secondary to hypovolaemia
and/or loss of vascular tone and a decreased systolic BP may
reflect impaired cardiac function. All these problems may be
present to varying degrees in children with meningococcal
sepsis. Our results confirm the importance of the measurement
and correct interpretation of blood pressure in ill children.

My Comment:

A very useful retrospective study in a country with similar
demography to New Zealand. The conclusions could usefully be
exported here.

The comments relating to the importance of measuring and
correctly interpreting the BP suggest this is an important
prognostic factor in ill children. The study showed, however,
that only 59% (62) of the patients had their BP recorded on
presentation.

Neisseria

Description of the features, diagnosis and treatment of
Neisseria disease.

A factual account written by Dr L O'Connor of the Department of
Microbiology, University of Western Australia.

Meningitis: NZ's third-world shame.

A Women's Weekly article published in July 2000.

Neisseria Meningitidis

A chapter from a textbook The Principles and Practices of
Infectious Diseases.

Detailed description of the disease.

Early Management of Meningococcal Disease

A guideline from RCGP.

It notes that low BP is a pre-terminal sign in children.

Early Intervention Saves Lives

Key messages from Dr J Jarman, MOH, […]

Red Flags in Common Paediatric Symptoms.

An article to alert nurse practitioners to elements of the
paediatric history that could herald urgent/emergent
conditions.

Meningococcal Disease 'Advice for GP Diagnosis and
Management'

NZ MOH 1998

The advice includes checking all skin areas for the presence of
a rash and concludes that if 'you do not suspect meningococcal
disease, encourage an early return and plan a review'.

New Guidelines for management and prevention of
meningococcal disease in Australia.

A comprehensive guideline focussing on management of someone
suspected of meningococcal disease.

Advise the practice of the profession in recording the
pulse, respiration and blood pressure of paediatric patients in the
accident and medical setting.

Practice in this regard will vary from one doctor and practice
to another. In general practice, we have traditionally worked
in a litigation free environment, which means that the medical
record will not reflect the depth and complexity of the
consultation that has taken place. This means that many
clinical signs will be observed but not necessarily recorded.

Of the three measurements, the pulse will be taken and recorded
most often.

Respiration will be noted, but the rate not necessarily
recorded, next often in sick people including children.
Doctors are more likely to record the type of respiration
especially if this is abnormal. For example, laboured breathing,
indrawing, expiratory wheeze, associated cyanosis, rather than
record the respiratory rate itself.

The BP will normally only be taken in a child in whom shock, for
any reason, is suspected.

However, a paediatric cuff for a sphygmomanometer is seen as an
essential piece of office equipment for general practice in the
Standards document 'Aiming for Excellence in General Practice'.

Interestingly, it is not part of the equipment carried in the
PRIME emergency bag. This is the bag of equipment carried by
rural GPs, practice nurses and ambulance officers who have
undergone training and work together in rural medical and trauma
emergencies.

The authors of the paper Invasive meningococcal infection in
Western Australia conclude 'Our results confirm the importance of
the measurement and correct interpretation of blood pressure in ill
children.'

They believe this to be an important prognostic factor.

It is very easy to determine that a child in shock is an 'ill'
child, such as Mr C was at his second visit to [the clinic].
The degree of 'illness' in a child in the earlier prodromol stages
of meningococcal disease is often missed as many of the papers have
reiterated.

This paper showed that only 59% (62) of the patients had their
BP recorded on presentation of their meningococcal disease.

This is a very interesting question to which some of the
material supplied by [Dr A] can be applied. I believe [Dr E]
acted with reasonable care and skill during both patient
contacts. I think that [Dr D's] professional actions were
carried out with adequate care and skill and considerable concern
for the child's welfare but that he could be criticised for failing
to adequately understand and act upon [Ms B] underlying, and as it
turned out, justified anxiety about meningococcal disease.

It is universally accepted, including by [Dr A], that
meningococcal septicaemia is not an easy diagnosis to make because
of its relative rarity and rapid progression to a shocked and
septic state. [Dr A] says, 'We are concerned that public education
on meningococcal disease leaves both the public and professionals
with the perception that the disease is meningitis, with signs of
neck stiffness, and other neurological signs. Meningococcal
septicaemia, which is far more dangerous, and likely to be fatal,
is missed in the early stages, when treatment is more likely to be
successful.'

This is reiterated in The United Kingdom Meningitis Research
Foundation guidelines, Meningococcal Meningitis and Septicaemia
Diagnosis and Treatment in General Practice. 'The information
widely available (about meningococcal disease) may be misleading
because it tends to focus on meningitis rather than
septicaemia.'

The guidelines also state that septicaemia is more likely to be
fatal when it occurs without meningitis. A patient with
septicaemia may present with very different symptoms from someone
with meningitis.

It is clear that this was the diagnostic mistake made by both
[Dr D] and [Dr E] during [Mr C's] first visit to [the clinic]. Both
actively looked for meningococcal meningitis and correctly
eliminated this. They both assumed a viral illness on the basis of
a dearth of hard clinical signs. In general practice, this is the
most common diagnosis that we see in children. Reassurance and
avoidance of antibiotics is normal practice in these situations.
Observation for a period may occur and it is stressed to
parents/caregivers to contact the doctor/clinic and return if the
child's condition worsens.

The diagnosis of meningococcal septicaemia seems not to have
been considered, a common mistake, as the papers provided have
shown.

[Mr C] was noted to have a significant illness of short
duration. He had vomited, had a high fever and was noted to
be weak, floppy and drowsy. [Mr C] mentioned a degree of
photophobia, which was selective i.e. to sun not artificial
light. The mother's background was provided, as was her
concern about meningococcal disease. [Ms B] pointed out a
significant tachycardia and the small coloured lesion in the right
elbow crease.

It seems to me that a reasonable and full examination was
undertaken on [Mr C's] arrival at [the clinic], although the
pulse and respiratory rate were not recorded. There does not
seem to have been any need to record the blood pressure at that
time. All systems were examined in an effort to locate a specific
source of infection. [Mr C] was appropriately given
paracetamol and brufen and monitored over nearly three hours.

[Ms B] says that she mentioned specifically the possibility of
'peripheral shutdown'. By this she meant that she had noticed that
[Mr C's] 'hands were cold, torso warm but not hot'.
Cool peripheries and a warm torso are often associated with a high
fever, as indeed [Mr C] had on his arrival at [the clinic]. These
signs settled as the temperature dropped. [Dr E's] notes
specifically mention 'warm peripheries' at her 3pm examination.

The eye symptoms/signs mentioned by [Dr A] do not bear a lot of
prominence for me. I agree that this is a 'soft sign', more likely
to be picked up by experienced doctors. Although eye signs are
mentioned in the accompanying papers, they relate particularly to
younger children and babies.

[Mr C] was extensively checked for signs of a rash. [Dr D]
did a complete physical check initially. Both [Ms B] and [Dr D]
'checked him all over for spots' after [Ms B] pointed out the
purple spot in [Mr C's] right elbow crease. [Dr D] pointed
out a 'typical' meningococcal rash from a textbook, which was an
advanced rash. [Dr D] later asked [Dr E] for a second opinion
and both looked for a petechial rash after [Ms B] pointed out the
spot on [Mr C's] right arm.

This may, in hindsight, have been a single purpuric spot and a
pointer to meningococcal disease but it is clear that the
rash/rashes of meningococcus were actively sought and not seen by
the examining doctors.

[Dr A's] reference says, 'the child must be stripped completely
when searching for petechial spots and also mucous surfaces such as
the palpebral conjunctiva, as important lesions can be missed'. It
is not unusual, in general practice, to strip all clothing off
children, other than babies, during an examination. However, a
detailed skin inspection can be done with a good light by lifting
up clothing or taking off selected pieces. I do not agree with
Professor Coster 'that a more detailed examination may have
revealed further lesions'.

The paper from the Royal Children's Hospital, Melbourne.
Bacteraemia in febrile children presenting to a paediatric
emergency department concludes, 'Most urban Australian children
aged 3-36 months presenting to a paediatric emergency department
with temperatures over 39 degrees without a clinical focus have a
viral infection. However, 3-4% have occult bacteraemia.
Neither the clinical features nor a high White Cell Count reliably
identify these patients. As empirical antibiotics may
contribute to increasing antibiotic resistance and have not been
shown to prevent the rare complication of meningitis, we believe
that close contact and regular review of these patients is
preferable to empiric antibiotic therapy.'

[Dr D] did not prescribe antibiotics empirically and he did
monitor and review [Mr C] for nearly three hours although the
monitoring consisted mainly of temperature taking and observation
of the child's general state.

The United Kingdom Meningitis Research Foundation guidelines
indicate that during the early, prodromal stage of the disease a
patient may present with a non-specific febrile illness that is not
always possible to distinguish from influenza or other
viruses. The symptoms and signs of the disease are described
as:

Before [Mr C] was released from [the clinic], he had perked up
but ominously vomited again on leaving the clinic.

An important statement is made in BMJ Education and debate
16/11/1996 Lesson of the Week: Who spots the spots? Diagnosis
and Treatment of early meningococcal disease in children.
'The first doctor to see a child with meningococcal disease needs
"knowledge out of proportion to their previous experience".
GPs and casualty officers need to be taught to recognise the rashes
of meningococcal septicaemia and to give "on the spot" penicillin
and not to delay treatment by looking for signs of meningitis.'

It seems clear that [Dr D] did not display 'knowledge out of
proportion to his previous experience'. However, he did display
very obvious concern and care and he undertook an adequate
examination. He looked for the typical rash of meningococcal
disease, which was not present. He then monitored the child for
nearly three hours.

[Dr D] said he offered to admit [Mr C] to hospital although [Ms
B] disputes this. Neither persuaded the other that this was
the right course of action for [Mr C]. In general the decision to
admit a child to hospital is made by discussion between the doctor
and parent/caregiver. If either feels strongly about the
issue, it is not difficult to persuade the other that an admission
should be sought.

I believe, and agree with [Dr A], that it would have been
prudent of [Dr D] to persuade [Ms B] that an early hospital
admission should have occurred on the basis of:

[Mr C's] continued vomiting.

The presence of a pulse rate of 160 recorded by [Ms B]. This
should have alerted [Dr D] to have monitored this expressly in
spite of the temperature dropping to normal levels.

[Ms B's] expressed anxiety about the possibility of
meningococcal disease.

The family's distance from the hospital in the event of
deterioration.

I do not think that this amounts to negligence or incompetence
but it shows some lack of judgement or inexperience or a mix of
these. Pressing for [Mr C's] early admission would have fulfilled
the BMJs statement ie 'The first doctor to see a child with
meningococcal disease needs knowledge out of proportion to their
previous experience'.

As stated in 'Recognising meningococcal disease in primary care:
qualitative study of how GPs process clinical and contextual
information'. BMJ 1998: the role of parents was perceived by
GPs as being very important in decision making about management -
in particular, taking account of perceived level of parental
anxiety about their child's condition.

The United Kingdom Meningitis Research Foundation guidelines
state: 'Since the disease can progress so rapidly, it is important,
subject to the GP's clinical judgement, that a patient, or parents
of a patient, with a non-specific illness who is not being sent to
hospital are given:

reassurance to trust their instincts and encouragement to seek
immediate medical help again if the patient's condition
deteriorates

information about the signs and symptoms of serious
illness'

[Mr C] was seen promptly and examined and monitored carefully.
His mother was advised to stay in town for a couple of hours and
return if deterioration in his condition occurred. This aspect of
the care of [Mr C] at [the clinic] cannot be criticised.

However the family situation was that the other children were
being minded by a friend which would have put pressure on [Ms B] to
return home. It might also have created difficulties returning with
a deteriorating child. The family lived in relative geographical
isolation from [the neighbouring public hospital] with its access
to technology and expert help. Rural patients need readier access
to public hospitals because of time and financial barriers than
those who live in urban centres. Recognition of and action on these
factors would have put [Dr D] into the category of being a first
doctor seeing a child with meningococcal disease having 'knowledge
out of proportion to his previous experience'.

Any other relevant matter?

There seems to be a desire to learn from this critical event and
to use [Mr C's] death in a positive way to improve understanding of
a terrible disease. It may be too late for mediation but
there may still be something to gain from a facilitated face to
face meeting, perhaps through Professor Coster, who has developed a
rapport with [the family]."

Dr Turnbull was asked the following further questions to clarify
her advice:

"[Ms B] in her 'Statement of Fact' states that she was concerned
'this might be meningitis' when she advised [Dr D] 'her father was
a GP who had diagnosed many cases …'. This concern that [Mr
C's] condition might be meningitis is reiterated in paragraph 2
when she states, 'after waiting two or three hours he said that he
felt it was a viral infection, not meningitis, as I had questioned
it was.' In paragraph three she states it was [Dr D] who
showed her a photograph of what a 'meningococcal' rash looked
like. Finally [Ms B] states that when she returned to the
clinic after [Mr C] vomited outside, '[Dr D] stated that he too was
getting paranoid - meaning that this may be a meningococcal
infection.'

[Ms B's] concern that afternoon was a concern about
'meningococcal disease' as well as 'meningitis'. You advise
that [Dr D] considered 'meningitis'.

What is the basis however for your conclusion that 'the
diagnosis of meningococcal septicaemia seems not to have been
considered'? That is, what actions or lack of action by [Dr
D] indicate to you that he failed to understand and act upon [Ms
B's] concern about 'meningococcal' disease?

Was the monitoring that did take place 'reasonable' for a
general practitioner, in light of current medical practice?
If not, what other monitoring, if any, should have occurred for [Mr
C] that afternoon other than temperature taking and observation of
his general state?

You stated in your advice, 'Before [Mr C] was released from [the
clinic], he had perked up but ominously vomited again on leaving
the clinic.' It needs to be noted, however, that [Ms B]
immediately took [Mr C] back into the clinic. [Dr D] sought
the second opinion of [Dr E], and the two doctors reassessed [Mr
C]. Sometime later, when [Mr C] had apparently settled again,
[Ms B] decided to take [Mr C] home and it was at home that further
vomiting occurred.

The nature and significance of the 'spot' is disputed
fact. However, you quote the statement made in the BMJ
Education Lesson of the Week dated 16 November 1996, concerning the
recognition of meningococcal rashes and giving 'on the spot'
penicillin. Are you saying (discounting the benefit of
hindsight) that [Dr D] should have given penicillin to [Mr C] that
afternoon?

While it is desirable to be able to display 'knowledge out of
proportion to previous experience', is this a reasonable
expectation? Is this the professional standard expected of
general practitioners in this situation?

Is the view that it would have been prudent to admit [Mr C] to
hospital that afternoon - based on the four criteria of continued
vomiting, a pulse of 160, specific maternal anxiety, and distance
from hospital - a view formed without the benefit of
hindsight? If so, at what point should [Mr C] have been
admitted to hospital that afternoon? Should any child be
admitted to hospital where those four criteria are present?"

Dr Turnbull provided the following clarificatory advice:

"I will attempt to clarify the questions that you ask in your
letter of 15/1/02.

…

I made the statement that 'meningococcal septicaemia seems not
to have been considered' because:

it is so rarely seen by an individual GP in his/her practising
lifetime. Therefore, it does not spring to mind whereas
meningococcal and other forms of meningitis and the plethora of
viral illnesses are being actively sought and treated every
day. I have been in fulltime general practice for thirty
years and have admitted numerous people to hospital with
meningococcal meningitis and with septicaemia but I have yet to see
i.e. diagnose, or misdiagnose a case of meningococcal
septicaemia. I believe that both [Dr D] and [Ms B] were both
actively 'thinking about' and excluded meningococcal
meningitis.

in addition, I do not believe that it was possible for anyone,
however skilled and experienced, to have diagnosed meningococcal
septicaemia in [Mr C's] case either when he was first seen or at
the end of the three hour monitoring period. [Mr C] was a
sick child with an undifferentiated illness until he returned the
second time.

I believe that the monitoring that took place was more than
reasonable for a GP practice i.e. it occurred over three hours, a
considerable time frame, and included observation and temperature
taking on a regular basis and before his return home a very careful
scrutiny of the skin for spots and rashes.

With regard to giving penicillin, no I do not think that this
should have been given. Modern practice is to discourage
empirical penicillin unless there is definite or very strong
evidence of a bacterial infection.

No, it is not a reasonable expectation for GPs to display
'knowledge out of all proportion to previous experience'. The
BMJ paper was published to provoke debate and aid education and it
is very clear about the difficulty of establishing a diagnosis of
meningococcal septicaemia.

I accept that there is debate/dispute over whether [Dr D]
offered and [Ms B] declined hospital admission for [Mr B]. I
can recall instances when I have felt reluctant to admit a child to
hospital as the diagnosis was not clear to me and have later felt
extremely grateful to the parents for the pressure that they
applied, subtly or directly, for admission. So it was with
that knowledge, and of course having been totally immersed in
meningococcal disease by studying all the attached papers, that I
made the statement that it 'would have been prudent to admit [Mr C]
to hospital that afternoon'. I am a rural GP too, so err on
the side of caution, whereas [Dr D] was practising in a moderate
sized city.

So yes, inevitably my view is formed with some hindsight and
many years in practice. I do not think that I can say that
the four criteria mentioned should automatically provoke a hospital
admission. …"

Code of Health and Disability Services Consumers' Rights

The following Rights in the Code of Health and Disability
Services Consumers' Rights are applicable to this complaint:

RIGHT 4

Right to Services of an Appropriate Standard

1) Every
consumer has the right to have services provided with reasonable
care and skill.

Opinion: No Breach, Dr D

Right 4(1)

In my opinion Dr D provided medical services to Mr C with
reasonable care and skill, and did not breach Right 4(1) of the
Code.

Introduction

When Ms B arrived with her son, Mr C, at the clinic just after
1pm on 9 April 2001 Dr D saw Mr C without delay. Dr D
examined Mr C, and diagnosed and treated him for a "probable viral
illness". Subsequent events later that evening proved that
diagnosis tragically wrong. Mr C had meningococcaemia
(meningococcal septicaemia). However, the issue is whether Dr
D's diagnosis and treatment, although incorrect, was reasonable in
the circumstances.

My first medical advisor stated that "Meningococcaemia is a
really rotten rapidly progressing deceptive disease which changes
quickly and is rapidly fatal. Its diagnosis is most often
extraordinarily difficult until it is very
obvious." The Medical Director of the clinic, Dr F, noted
that meningococcaemia was "notoriously difficult to diagnose and
definitive signs often present last". Dr A, the complainant
and Mr C's grandfather, stated that "the presenting clinical
picture of meningococcal septicaemia is notoriously
misleading". My second medical advisor, Dr Turnbull,
noted:

"It is universally accepted, including by Dr A, that
meningococcal septicaemia is not an easy diagnosis to make because
of its relative rarity and rapid progression to a shocked and
septic state."

Diagnosis

Staff nurse Ms G took an initial triage history, measured Mr C's
temperature at 39.8 and weighed him. Mr C had vomited in
reception and Ms B observed he was unsteady on his feet as he was
weighed. Ms B reported the nurse as
commenting "not to worry about holding him".
No unsteadiness was documented. Dr D then took a history of
Mr C's illness directly from Ms B and physically examined
him. Dr D documented that the cardiovascular, respiratory,
ear, nose and throat and abdominal systems were all normal and no
abnormalities could be detected. Dr D prescribed Pamol and
Brufen syrup and ordered that Mr C's temperature be monitored every
15 minutes.

Dr D stated that he reached his diagnosis on the basis of the
following information:

He responded to the paracetamol with a reduction in temp and
improved wellbeing. …"

Mr C's temperature dropped over the following two hours from
39.8 to 38.7 and then to 36.5 at approximately 3.15pm. Ms B
wrote that Mr C "was conversant and the most awake he'd been for
hours before he left the clinic".

Dr D also specifically checked for signs of meningitis and
documented "CNS no photophobia, no meningism, negative Kernig's",
"no petechial rash" and "no evidence of meningitis".

Disputed symptoms

There is a conflict of evidence about whether Mr C was
photophobic, peripherally shut down, and had a meningococcal rash,
and about the significance of the look in Mr C's eyes.

First, Ms B disputed that Mr C did not have photophobia as she
recalled that Mr C had complained to her earlier that the sun hurt
his eyes. However, when Dr D checked Mr C for photophobia, Mr
C said that "that [artificial] light does not hurt my eyes but the
sun does".

Secondly, Ms B stated that Mr C was peripherally shut down:

"The time was 11'ish … On checking him I found his hands cold,
torso warm but not hot. Again I thought this strange, as the
day was … warm … I immediately thought that the only thing that
would cause this was peripheral shutdown."

However, when Mr C was first examined by Dr D just over two
hours later he documented that Mr C's cardiovascular system was
normal. My first medical advisor noted that at 3pm, when Mr C
no longer had a fever, Dr E documented that Mr C had "warm
peripheries, normal capillary return".

Thirdly, there is conflicting evidence about the "spot" Dr D and
Dr E looked at. Ms B stated the spot was a "deep purple spot
… with a red halo … about 2mm in diameter" in Mr C's right
ante-cubital fossa. Dr D stated that following a conversation
about meningitis "[Mr C's] mother and I checked him all over for
spots and did find 2 blemishes on his right upper arm. These
did not look petechial at all, but because she was unsure whether
they were new or not, I asked my colleague Dr E to review [Mr
C]." The spot recorded in Dr E's notes, however, does not
refer to Mr C's upper arm or ante-cubital fossa but to "a light
brown spot on the mid-chest". However, Dr E later that
evening inserted a 22-gauge IV cannula in Mr C's right ante-cubital
fossa. I accept my first medical advisor's advice that it
would be "[unlikely] that Dr E would have missed such a sign
[petechial rash] in the area she cannulated if it had been
apparent". My advisor also stated that "1 small spot does not
constitute a meningococcal rash".

Fourthly, Ms B stated that she told Dr D about her concern Mr C
might have meningitis, informing him that her father was a GP who
had diagnosed many cases, and had remarked that many cases had
"this odd look about the eyes. That they looked through you
rather than at you." Dr I, a colleague of Dr A, stated:

"The far away look in his eyes is a most important sign. …
This is a feature noted by myself as well as my colleagues as a
common and significant sign in adult as well as paediatric patients
with meningococcal septicaemia."

Dr A sought comment from Professor Gregor Coster. He
commented that the examination was incomplete and the seriousness
of the illness was not recognised in the presence of the history,
fever, photophobia, peripheral shutdown/shock and petechial
rash. However, I note that whether Mr C was photophobic,
peripherally shut down or in shock with a petechial rash is
disputed.

My independent medical advisors did not accept that Dr D's
examination was incomplete or his diagnosis substandard.

My first advisor
stated:

"The eye signs must be disregarded: it is not an acceptable
clinical indicator. Certainly sick people get a glassy vacant
feverish stare but I do not know that this is different for a
septicaemia (or for that matter meningitis)."

My first advisor acknowledged that
interpretations of "soft" clinical signs are "part of the general
assessment of how sick the child looks" and that clinical acumen is
a "nebulous thing" that increases with experience in general
practice. It is a matter of "experience and judgement" and it
is this that will "differentiate the 'really GUN' diagnosticians
from competent ones".

My first advisor also stated:

"On the information presented it was reasonable to diagnose a
'viral illness' given the signs and symptoms at 1-3pm. Mr C
did seem to rally and settle as the fever settled (documented)
after the paracetamol. There are no 'hard' clinical features
… to indicate the seriousness of the illness.

…

If any signs were apparent, which cannot be inferred, they were
not missed through incompetence. Dr D exercised reasonable
care and judgement. … [D]iagnosis [of meningococcaemia] is
extraordinarily difficult until it is very
obvious. It was 5½ hours from the time he left the clinic
until he returned - a long time in the course of
meningococcaemia."

My second advisor stated:

"… I do not believe that it was possible for anyone, however
skilled and experienced, to have diagnosed meningococcal
septicaemia in Mr C's case either when he was first seen or at the
end of the three hour monitoring period. Mr C was a sick
child with an undifferentiated illness until he returned the second
time."

I accept that, given all the circumstances of Mr C' initial
visit to [the clinic] of the afternoon of 9 April 2000, it was
reasonable for Dr D to have diagnosed a viral illness, and to have
failed to diagnose meningococcal septicaemia. Accordingly, in my
opinion, Dr D did not breach the Code in relation to his
diagnosis.

Treatment

It follows that, as Dr D's diagnosis of a "probable viral
illness" was reasonable in the circumstances, it was also
appropriate to treat Mr C as if he had a viral illness. I
accept my expert advice that Pamol and Brufen syrup in combination
is appropriate and effective treatment for what is thought to be a
febrile viral illness.

I also accept my second advisor's advice that penicillin should
not have been given to Mr C during the afternoon of 9 April
2000. I note Dr Turnbull's advice: "Modern practice is to
discourage empirical penicillin unless there is definite or very
strong evidence of a bacterial infection."

Accordingly, in my opinion, Dr D did not breach the Code in the
treatment he prescribed for Mr C on the reasonable assumption he
had a viral illness.

Monitoring and review

The clinical record documents that Mr C's temperature was taken
three times, on admission at approximately 1.15pm, at 2.30pm and
then at an unspecified time. This record shows a downward
temperature trend from 39.8 to 38.7 to 36.5. Although, at Dr
D's request (and as confirmed by Ms B), Mr C's temperature was
taken every 15 minutes by the nurse, no record was kept at these
intervals. There was also no record of any
pulse or respiratory rate and only one blood pressure recording,
when Mr C was readmitted at approximately 9.00pm.

Dr F admitted in the clinic's internal review of the notes that
the "record keeping should have been better" but queried whether in
"retrospective analysis … a diagnosis [could] have been made".

My first advisor stated:

"[A] pulse of 162 would alarm me. It is a bit too high for
a viral fever. Taking the BP, if it had been low in
conjunction with the very high pulse may have alerted to the
possibility of a more serious illness e.g. septicaemia. A
very shallow rapid breathing rate would have supported this concern
i.e. some signs of 'inordinate prostration'."

However, my advisor stated that "the signs if abnormal could
have other explanations, (e.g. the fever)". Mr C had
clinically improved and by the time he left the clinic was afebrile
and the brightest he had been for hours.

I agree with Dr F's statement that "the record keeping should
have been better". I also accept my first advisor's statement
that "these things can be observed but not recorded".

My second advisor commented as follows in relation to monitoring
pulse, respirations and paediatric blood pressure:

"Of the three measurements, the pulse will be taken and recorded
most often.

Respiration will be noted, but the rate not necessarily
recorded, next often in sick people including children.

The BP [blood pressure] will normally only be taken in a child
in whom shock, for any reason, is suspected."

Mr C's temperature was monitored every 15 minutes by the
nurse. Dr D had examined Mr C's cardiovascular and
respiratory systems and in the course of doing so would have
listened to Mr C's breathing and heard his heart rate, and
documented those systems as normal. Dr D also frequently
observed Mr C as he slept, and noted that his temperature was
trending down. Mr C was afebrile at approximately 3.20pm and,
as described by Ms B, "conversant and the most awake he'd been for
hours".

Dr D did not ignore the spot on Mr C's right arm but made a
clinical judgement that the spot was not "petechial". Dr D
sought a second opinion from Dr E, who made reference in her notes
to a spot resembling a freckle on Mr C's chest, but did insert an
IV cannula into Mr C's right ante-cubital fossa that evening.
My advisor stated that, had a significant clinical sign been
present in that area at that time, Dr E would have been unlikely to
miss it.

I accept my second advisor's advice:

"… [T]he monitoring that did take place was more than reasonable
for a GP practice i.e. it occurred over three hours, a considerable
time frame, and included observation and temperature taking on a
regular basis and before his return home a very careful scrutiny of
the skin for spots and rashes."

I accept that Dr D appropriately monitored Mr C throughout his
afternoon stay at the clinic. I note that Dr D's failure to
record Mr C's pulse and respiratory rate was not best
practice. However, in my opinion Dr D did not breach the Code
in relation to his monitoring of Mr C's condition during the
afternoon of 9 April 2000.

Leaving the clinic

When Ms B informed Dr D that she lived half an hour out of town,
he asked her "to stay in town for a couple of hours" in case there
was any change in Mr C's condition. Dr D told Ms B that "if
Mr C's condition changed, to bring him straight back to the clinic
or to go to the hospital".

Dr D also stated that he offered Ms B the option of
hospitalising Mr C for monitoring. Ms B, however, strongly
denied that this offer was ever made. If an offer was made,
it was not documented, although I accept that such an offer would
not necessarily be documented. In all the circumstances it is
unclear whether an offer was in fact made. Even in Ms B's
anxiety, it seems likely that she would have accepted such an
offer, and taken Mr C to hospital if it had been made.
Instead, Ms B "decided to go home due to my other children being
there with [a friend], so I left and went home". Dr D wrote
on the clinical notes, "Review prn [as necessary]".

Concerns of Ms B

Ms B complained that Dr D did not heed her concerns about
meningitis or meningococcal disease. I accept that while Mr C
slept Dr D had discussions with Ms B about meningitis and the signs
and symptoms to look for. Dr D did check for signs of
meningism and documented that none were found. Ms B wrote
that Dr D said "he felt it was a viral infection, not meningitis,
as I had questioned it was". Ms B disagreed with Dr D's
diagnosis but I do not believe that he failed to heed her concern
about meningitis.

Ms B stated that she was also concerned Mr C might have
"meningococcal disease". Ms B reported that when she took Mr
C back into the clinic after he vomited outside the pharmacy "Dr D
stated that he too was getting paranoid - meaning that this may be
a meningococcal infection". Dr D showed Ms B a textbook
illustration "of what the 'rash' (meningococcal) was really like",
and asked his colleague, Dr E, for a second opinion. Again, I
believe that Dr D did heed Ms B's concerns and contemplated the
presence of meningococcal disease, but maintained his incorrect
diagnosis of viral infection.

In commenting on the quality of the communication between Dr D
and Ms B, my first advisor stated that the doctor-patient
relationship involves "Complex judgements: how accurate an
historian is the mother - does she over or understate problems, how
observant is she? This can be extremely difficult in an
emergency where the doctor has no prior relationship, no way of
validating either the doctor's perception of the parent or the
parent themselves." I agree with these comments.

I also acknowledge my second advisor's comments about her
experience as a rural GP:

"I can recall instances when I have felt reluctant to admit a
child to hospital as the diagnosis was not clear to me and have
later felt extremely grateful to the parents for the pressure they
applied, subtly or directly, for admission."

Dr D was aware that Ms B had a nursing background and that her
father was a local general practitioner. Ms B was first and
foremost Mr C's mother, who as his primary caregiver knew him
best. Weight should always be given to the insight and
concerns of a parent and considered very carefully. It would
be professionally inappropriate to surrender clinical diagnostic
judgement to those concerns. Nonetheless, I agree with my
first advisor that the concerns of Ms B, as Mr C's mother and a
trained health professional, "do rather seem to have been
underestimated". I am, however, unable to conclude that Dr D
did not heed the concerns of Ms B regarding the presence of
meningitis or meningococcal disease.

In all the circumstances, in my opinion, Dr D did not breach the
Code in the way in which he took account of the concerns of Ms
B.

Opinion: No Breach, Dr E

Right 4(1)

In my opinion Dr E provided medical services to Mr C with
reasonable care and skill, and did not breach Right 4(1) of the
Code.

Dr E was asked by Dr D to give a second opinion on Mr C'
condition at approximately 3pm on the afternoon of 9 April 2000 at
the clinic. Dr E stated that Dr D asked her to look at a spot
on Mr C's chest and explained to her that Mr C had presented with
"a high temperature which had settled and vomiting".

Dr E documented that Mr C was "afebrile, alert, talking, warm
peripheries, normal capilliary return. No meningeal
[symptoms] - no photophobia, no neck stiffness, Kernig
[negative]". Dr E examined the spot on Mr C's chest with Dr D
and described it as resembling a freckle. Dr E did not
comment on the spot in Mr C's ante-cubital fossa described by Ms
B. I accept my expert advice that if the spot had clinical
significance Dr E would have been unlikely to miss such a sign in
the area where she later inserted an IV cannula. Dr E agreed
with Dr D that Mr C had a probable viral infection.

My first medical advisor stated:

"The duties and obligations of a doctor asked for a second
opinion are to frankly evaluate the information presented and reach
an independent diagnosis, which should then be compared to the
original doctor's ideas. Each should then evaluate the 2
opinions, discuss as necessary and achieve a consensus in the
patient's interest. This seems to have happened."

When Mr C later re-presented to the clinic at approximately 9pm
that evening, Dr E immediately recognised that Mr C was "septic,
shocked and shut down with mottled blue/red skin discolouration and
cool peripheries". Dr E acted appropriately in directing that
the ambulance be contacted for an emergency transfer to hospital,
establishing IV access and administering benzylpenicillin and a
250ml bolus of Haemacel.

My first advisor commented:

"Dr E seems to have acted with a reasonable standard of care -
she only saw Mr C (during the first presentation) when he was
better - having responded to the medicines he was given. She
also acted with speed and acumen when he presented a second
time."

In my opinion Dr E did not breach the Code by failing to
recognise or diagnose meningococcal disease when asked for a second
opinion by Dr D.

Opinion: No Breach, The Medical Clinic

Right 4(1)

In my opinion the medical services provided by the clinic did
not fall short of the standard of reasonable care and skill
expected of a medical clinic, and did not breach Right 4(1) of the
Code.

Mr C, aged four years, died on 21 April 2000 of complications of
meningococcal septicaemia. On 9 April 2000 Dr D, a general
practitioner employed by the clinic misdiagnosed Mr C with a viral
illness. As a result of my investigation I have found that Dr
D was not in breach of Right 4(1) of the Code. During the
course of his care for Mr C on the afternoon of 9 April 2000, Dr D
consulted with his colleague, Dr E, who was also employed by the
clinic as a general practitioner. Dr E also failed to
diagnose that Mr C was very seriously ill with meningococcal
septicaemia. I have found that Dr E was not in breach of
Right 4(1) of the Code.

The clinic appropriately carried out an internal investigation
and undertook a peer review of the case management and standard of
care provided by Dr D and Dr E. The peer review found the
management of the case appropriate and the standard of care "good",
although the record keeping should have been better. In light
of my subsequent investigation and findings that Dr D and Dr E did
not breach the Code of Health and Disability Services Consumers'
Rights, I am satisfied that appropriate systems were in place at
[the clinic].

Accordingly, no question of direct or vicarious liability on the
part of the clinic arises.

Actions

A copy of this opinion will be sent to the Medical Council of
New Zealand and the Director of Public Health.

A copy of this opinion, with all identifying features removed,
will be sent to the Royal New Zealand College of General
Practitioners and posted on the Health and Disability Commissioner
website ().

Other Comments

It is now almost two years since Mr C died. This has been
a sad and difficult case to investigate. This final report
may be greeted with disappointment by Mr C's family, in particular
his grandfather, Dr A, who has meticulously documented his own
research on the diagnosis of meningococcal septicaemia in general
practice. However, I reject Dr A's observation that my report
endorses the "stance of cronyism [within the medical profession] to
the detriment of the user of the service". The tragedy
of Mr C's death should not be compounded by unjustified allegations
against the well-intentioned practitioners and advisors involved in
this case.